Provider Demographics
NPI:1508188053
Name:FORRESTER, JAMES CRAIG
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:CRAIG
Last Name:FORRESTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-2124
Mailing Address - Country:US
Mailing Address - Phone:231-627-7139
Mailing Address - Fax:231-627-5358
Practice Address - Street 1:1131 E STATE ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2124
Practice Address - Country:US
Practice Address - Phone:231-627-7139
Practice Address - Fax:231-627-5358
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1927170Medicaid
MI2343870OtherNCPDP PROVIDER IDENTIFICATION NUMBER
P00151803Medicare PIN
MI2343870OtherNCPDP PROVIDER IDENTIFICATION NUMBER